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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO%.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;r�ZoZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -ia <br /> (Complete In Triplicate) ( �3 /tc?-O2- <br /> Application is hereby made to the San Joaquin Local Health District for a permit: to const7'uct <br /> and/or install the work herein described. " This application is made in compliance with Saar Joaquin <br /> County Ordinance No. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION- ti 'i �Sr/ D <1r�"-rte 720A)t-01V /R9SUS TRACT " <br /> Owner's Name <br /> _ Phone 'q r]'/ �- <br /> Address leg z-C/ . l.. € Cl �'-t5 rl! City <br /> Contractor''s Name � (�I�1}ms's License 116 3"73 Phone4t-g��f�' <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/—/ RECONDITION J / DESTRUCTION /`7 <br /> PUMP INSTAL TION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_7 ,A <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE9PAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial E Cable Tool Dia. of Well Excavation <br /> Domestic/private r Drilled Dia. of Well Casing <br /> Domestic/public t. Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal /U a,A1.0 <br /> Other . k Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Cont actor <br /> Type hof Pump H.P. - <br /> PUMP <br /> .p. .PUMP REPLACEMENT: <br /> / / 'State Work Done <br /> PUMP `tPAIR: —� �/ J -State Wbrk Donees_ ' <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> c Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a � <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above � <br /> information is true to the best of my knowledge and. belief. <br /> SIGNED TITLE �wr <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � t <br /> APPLICATION ACCEPTED .BY - DATE <br /> ADDITIONAL COMMENTS: I ; <br /> PHASE II GROUT INSPECTION PHASE III/.FINAL INSP CTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 r i-� <br />